Fraud and Abuse

FRAUD HOTLINE1-800-372-8321

What is healthcare fraud, and why is it a problem?

Fraud occurs when a dishonest member, doctor or hospital lies on an application or claim
form with the intention of receiving a payment from USAble Mutual Insurance Company to
which they are not entitled.

Whoever knowingly and willfully executes, or attempts to execute, a
scheme or artifice — To defraud any healthcare benefit program; or To obtain,
by means of false or fraudulent pretenses, representations, or promises, any of
the money or property owned by, or under the custody or control of, any
healthcare benefit program, in connection with the delivery of or payment for
healthcare services, shall be fined under this title or imprisoned not more
than ten years or both.

Fraud and abuse accounts for between 3 and 10 percent of the
annual expenditures for healthcare in the United States. We all pay the price through
higher premiums and healthcare costs.

What are common types of fraud?

Providing false statements on an application;

Submitting claims for services that were not performed;

Misrepresenting services that were provided;

Providing medically unnecessary services.

What are the penalties for committing healthcare fraud?

Healthcare fraud is both a state and federal offense. As stated in the HIPAA
Act of 1996: (18USC, Ch. 63, Sec 1347), a dishonest doctor, hospital or member is
subject to fines or imprisonment of not more than 10 years or both. Making
false or misleading statements on an application carries a maximum five-year
sentence.

Fraud Hotline

The detection, prevention and elimination of fraud, abuse and over-utilization are
essential to maintaining a healthcare system that is affordable for everyone now
and in the future.

We aggressively investigate and pursue the prosecution of the perpetrators of healthcare
fraud, abuse and over-utilization, including doctors and hospitals of medical and other related
health services, agents, members and others.

We actively cooperate with criminal investigations conducted by federal, state and
local authorities, encourage education and conduct awareness programs to alert our
employees, members and the general public to potential fraud or abuse.